Looked at the ASTRO discussion board and to my surprise, thought it was fair, with most academic leaders acknowledging dangers of residency expansion. Here are posts by prominent docs (I left out names) for medical students who dont have access. Given the overall sentiment on the board by many former program directors and really prominent voices in this field, it is absolutely shocking ARRO would suggest that medstudents ignore concerns over job market. Total loss of credibility,
"I have concerns about how the workforce supply will impact the quality of applicants and future trainees. Our specialty is nearing the end of it's gilded age and the high volume of physician-scientist (MD-PhD), research driven candidates with lofty board scores is starting to thin out. This is partly due to the fact that some graduating residents are challenged trying to find the best job in the best geography and partly due to the fact that our specialty simply didn't have the high level academic posts for those wanting a physician scientist career. Very few programs have a strong, robust cancer biology program with sufficient grant support and research space to keep them in academia. This is where our societies like ASTRO, ACR, RSNA, etc can help. We need to find a means to invest in the future of our specialty by expanding research opportunities. It's why the Radiation Oncology Institute (ROI) was created and why I support it!
As those top candidates now pursue alternative specialties and careers are we going to see the quality of candidates and future residents decline? Will programs go unmatched? I doubt it. I think we will see some programs fill in the post match scramble with candidates ill prepared or motivated for a career in radiation oncology."
"In my opinion, YES, we are training too many radiation oncologists. Many of the points have already been made so I won't restate them. Perhaps the most important point was by Dr. Chronowski (sp?) who reminded us that organizations such as AAMC, ASTRO, ACR, etc, CANNOT weigh in on this formally, as it could be interpreted as anti-trust.
Radiation therapy is used for ~2/3 of all cancer patients, by most estimates. So with ~1.5M cases per year, one could estimate ~1M patients a year requiring RT per year. Cancer incidence is growing and, presumably, RT utilization will follow, but this may be ouweighed by the impacts of hypofractionation and the impact of AI in our field.
Hypofractionation is becoming increasingly utilized and at some point, AI will enter our space, specifically in contouring and treatment planning. Both of these developments will significantly impact workforce requirements. I'm not as convinced that true computer-assisted decision support (CADS) will replace or even meaningfully impact our cognitive thought, but we shall see."
"Yes. Reduce the number of residency positions. Frequently the number of residency slots is driven by the need for inexpensive manpower in programs which, for the most part, depend on residents to perform tasks that could be performed by RNs, ARNPs, PAs, secretaries, and attendings. I have been on faculty since 1982 and work in two locations in a university based practice where one is resident dependent and the other is not. While it is a difficult transition to make, it can be done and is necessary for the health of our specialty. This impending problem has been apparent since the mid 1990's and could have been avoided if we had the discipline to make some difficult choices."
"I wanted to make the point that unbridled residency expansion + decreasing number of fractions via hypofractionation/SBRT is simple math (see attached figure).
Between 2000 - present, we have effectively doubled the number of Radiation Oncology residents. We have publications demonstrating that the Radiation Oncologist need was vastly overstated. ASTRO Choose Wisely recommends that virtually all breast cancer treatment lengths be cut in half. Prostate is coming next."
"I say all this to emphasize that the trends are all looking bad. We can simply dismiss the warnings as tin-foiled hat rantings of a bunch of malcontents and anonymous internet trolls or we can accept the quantitative reality for what it is, sit down, come up with solutions and save our specialty."Dr. Michalski's concerns are well grounded - we are seeing a decrease in the number of applicants and, as Dr. Lee points out above, this year the number of spots offered through The Match is greater than the number of applicants (down to 190 (2019) applicants from 221 (2018), 235 (2017), 223 (2016)). These unfilled spots can be filled post-Match. We may also see an increase in non-US graduate interest as the "barrier to entry" is lowered. This may be reflected in the metrics published in the NRMP's Charting Outcomes of the Match by showing RO as "less competitive". Ultimately, this may impact the quality of the workforce (although quality can mean many different things, and ROs that give excellent patient care but are less interested in research should be valued, particularly in the setting of maldistribution)
"- Concern regarding the future of the specialty and future employment prospects has led medical students to be actively discouraged to pursue the specialty by many current residents and practicing ROs. This may be driving the first point above.
- Just because a program is approved for a certain number of spots by the ACGME does not mean they have to fill them. Individual action can be taken to decrease the number of spots (not collective action, which would be perceived as antitrust as above)
- It is an oversimplification to say that decreasing number of fractions (hypofractionation/SBRT) will lead to bleak employment prospects, but yes, the average number of fractions delivered has decreased across all disease sites over the last decade, and that trend will likely continue.
- To answer the original poster's question, "do you perceive this to be a problem" - the answer is yes – the 2017 ASTRO Workforce Study showed a majority (53%) of ROs are concerned about a future oversupply of ROs (up +20% from the 2012 survey!).
- A final point that has not yet been raised- just as it is disingenuous increasing training minimums solely as a way to manage the workforce, so it is it disingenuous to have a rise in fellowship training secondary to supply-and-demand issues, as opposed to a true need for further specialization. This is something to monitor as the number of RO fellowships are increasing (n.b. these fellowship are not ACGME accredited)"
"It is an oversimplification to say that programs are paid by Medicare according to the number of positions. Medicare has capped spots for more than two decades. Many programs pay for residents through professional revenue, hospital system support, philanthropy or some combination of these.
I was on the RRC of ACGME for 6 years and chaired the committee my last three years. The ACGME is forbidden from using workforce in deciding whether programs can expand or new programs begin. There is an application process; if the patient numbers, attending physicians and facilities are sufficient than a request for increase is granted.
In my view we are two problems: 1) overtraining (too many physicians) when market forces are reducing demand (hypofractionation, capitation) AND 2) geographic maldistribution. The first problem is more important to address.
Unfortunately until training programs decide to limit training positions on their own, nothing will be done.
In a related note, this is likely the first year in more than a decade that the number of training spots is GREATER than the number of US graduates applying.
Not good for our discipline."
